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Al Dorof, Editor


Sexual and Reproductive Health in the Developing World

Women around the globe often face significant challenges to their sexual and reproductive health, including lack of access to reproductive health-care services, early marriages and pregnancies, high rates of pregnancy-associated morbidity and mortality, and HIV infection rates well in excess of the men in their communities.

It is reason for optimism that Margaret Chan, upon her appointment in November 2006 as the next Director-General of the World Health Organization (WHO), told the World Health Assembly she wanted to be judged by WHO's impact on two key indicators: the health of African people and of women across the globe. "I do not mean just maternal health," she explained. "Women do much more than have babies. Unfortunately, their activities in households and communities, coupled with their low status, make them especially vulnerable to health problems — from indoor air pollution and multiple infectious diseases to violence."

Against this backdrop, four Bryn Mawr alumnae who are working to improve sexual and reproductive health around the world offered their insights on challenges and progress in these areas for men and, particularly, for women.

Lacking Power and Choice

Annabel Erulkar '87
Annabel Erulkar '87

HIV is a critical and growing threat to people in sub-Saharan Africa, where approximately 6.1 percent of adults between the ages of 15 and 49 are infected [Source: UNAIDS 2006 Report on the Global AIDS Epidemic ], and it is increasingly an epidemic of young women. "In some parts of sub-Saharan Africa, young women from the ages of 15 to 24 have HIV infection rates two to eight times those of men," says Annabel Erulkar '87, director of the Population Council's Poverty, Gender and Youth Program in sub-Saharan Africa, which focuses on the sexual and reproductive health issues of adolescent girls and young women. In this post, she works extensively with program staff in Ethiopia, Kenya and Nigeria from her base in Accra, Ghana .

"Many sexual and reproductive health/HIV programs tend to focus on risk-taking behavior and education. Our program attempts to take a broader view of what makes a young woman vulnerable and what puts her at risk of negative reproductive health outcomes, including HIV infection," Erulkar says. "Some of the under-appreciated issues in this part of the world include lack of power and choice, especially among girls and young women.

"A significant proportion of young women experience forced or coerced sex, yet programs rarely address the power dimension of sexual relations," Erulkar explains. "Our program addresses issues such as child marriage, for example, which almost always includes lack of power and decision-making capability on the part of the girl and frequently results in forced sexual initiation and early pregnancy."

In Ethiopia, the Population Council partnered with the Ethiopian Ministry of Youth to conduct research on young people in remote rural areas of the country and slum areas of Addis Ababa, which highlighted the most vulnerable segments of youth in these settings. "In rural areas, a large proportion of girls and young women are married early, mostly without their knowledge or consent," Erulkar observes. "We found married adolescents to be extremely vulnerable, yet neglected by traditional interventions, and in need of programs to support them.

"In slum areas of Addis Ababa ," Erulkar continues, "a considerable number of girls are engaged as domestic workers, many of whom, in fact, have migrated to the city to escape forced marriage in their rural home areas. These girls are poor, isolated and vulnerable, working extremely long hours for next to no pay. With few other options, these girls and young women either put up with abusive working conditions or often drift into sex work, where there is better pay."

Strained Infrastructure

Cynthia Eyakuze-Di Domenico '94
Cynthia Eyakuze-
Di Domenico '94

The sexual and reproductive health issues in the countries of French-speaking West Africa are similar, in many ways, to those in southern Africa , yet there are also stark differences. "In Mali, Niger and Burkina Faso, the major reproductive health issues are early unwanted pregnancy and sexually transmitted diseases, as well as high maternal mortality and morbidity," says Cynthia Eyakuze-Di Domenico '94, acting director of the Francophone Africa Program at Family Care International, based in New York. "In Niger, for example, a woman has a 1-in-7 lifetime chance of dying during pregnancy or childbirth compared with a 1-in-30,000 chance in Sweden."

Early marriage and lack of access to reproductive health education are among the social, cultural and economic issues related to early unwanted pregnancy in the region. "Poverty at the micro and macro levels intersects with gender dynamics," says Eyakuze-Di Domenico. "For example, girls are more often pulled out of school to work in the fields. In addition, it can take days for a woman to travel to a health center that provides even minimal maternal care.

"Abortion also kills a lot of women," Eyakuze-Di Domenico continues. "It is illegal under most circumstances, and poor women don't have access to safe abortions."

HIV prevalence is much lower in this sub-region compared with other parts of sub-Saharan Africa — less than one percent in Niger, around two percent in Mali and four percent in Burkina Faso, according to Eyakuze-Di Domenico. "Yet there are certainly pockets of higher HIV prevalence among vulnerable groups," she says. "Youth are vulnerable, particularly young girls."

The lack of health-care resources is a tremendous challenge in the region. "The government is not training enough health-care workers," Eyakuze-Di Domenico observes, "and certain policies imposed from the outside, including the World Bank and International Monetary Fund, have put hiring caps on civil servants, including teachers and health-care workers. As a result, the health and education sectors have been negatively affected."

Health-care centers are few and far between, and existing centers are not well-equipped. Moreover, Eyakuze-Di Domenico says, "Women's health is always on the bottom rung in terms of government priorities for resources. A government may allot $3 per capita for health, with most of that going to the tertiary level, such as university hospitals."

Scant Research

Shireen J. Jejeebhoy '73
Shireen J. Jejeebhoy '73

Similar conditions exist in India, where half of all women are married before the age of 18, and about a quarter by the time they are 15, generally without their consent. "Sexual initiation occurs earlier among young women, and more often among adolescent girls than boys, simply because they are married so young," observes Shireen J. Jejeebhoy '73, a senior program associate with the Population Council, based in New Delhi. " Young married women are increasingly at risk of HIV despite the fact that they do not fall into defined high-risk categories because they are monogamous, yet they are ignored by many sexual and reproductive health programs. From our research we have learned that so many young women have never heard of HIV/AIDS."

Jejeebhoy's groundbreaking research focuses on young people's sexual and reproductive health and rights, as well as women's access to abortion. There had been no large-scale community surveys about the sexual and reproductive practices of young people until three years ago, when she and her colleagues conducted a survey of almost 9,000 young women and men between the ages of 15 and 24, both unmarried and married, in the Pune district near Mumbai. She is in the process of conducting a similar study at the state level in six Indian states.

The research has revealed major gender imbalances and power differentials among young people. "Women have little ability to exercise choice in their own lives, whether they are married or unmarried," Jejeebhoy says. "Their mobility and decision-making are constrained, they have little access to money, and they are more likely to be discontinued from school. They are at a huge disadvantage compared with young men."

Jejeebhoy has also found that early sexual relations within marriage are often traumatic for young women. "Many young married women say that they have been forced by their husbands to have sex — and the husbands will acknowledge that," she says.

Young married women are also vulnerable to the increased risks associated with adolescent pregnancy. "And when young girls seek abortion, they are more likely than adult women to seek it from an unqualified provider in late pregnancy," Jejeebhoy has found.

Abortion is legal in India if it is performed by a certified provider in a registered facility. "But access is a huge problem," Jejeebhoy says. "The more rural a woman's location, the more difficult it is to get a safe abortion."

Living Their Nations' Values

Elizabeth Arend '02
Elizabeth Arend '02

In research conducted as an undergraduate, as a Thomas J. Watson Fellow and as a master's candidate in public health, Elizabeth Arend '02 has observed direct links between women's status and sexual and reproductive health indicators — both in developed and developing countries. Her studies include HIV-positive women of color who have sex with other women in the United States, African and European refugees living in Ireland, and women seeking abortions from Women on Waves, a Dutch organization that provides sexual and reproductive health services on board a ship traveling in international waters.

Arend's Watson fellowship culminated in a paper on reproductive health care, law and policy in Egypt, Ireland, Holland and South Africa . "I would say that in every country, regardless of the level of development, the values of the nation-state are inscribed on women's bodies and lived in their physical experience, and that is reflected in women's sexual and reproductive health," she says.

For example, Arend says, "In Ireland, every step of the way there were so many hurdles to obtaining reproductive health services, which violated a woman's privacy and ultimately forced her to go abroad for services. It was remarkable to see how many women were responsive to Women on Waves when the ship came to Dublin and Cork ."

In the United States, Arend observes, "We can see the effects of conservative religious ideology in the recent threats to Roe v. Wade, the ban on the 'partial-birth abortion,' and other attempts to chip away at women's reproductive rights."

Arend currently is a postgraduate fellow in the Yale University-William J. Clinton Foundation's Ethiopian Hospital Management Initiative, which was designed in response to the Ethiopian health minister's goal to enhance management capacity in selected hospitals and develop a model of systemic changes for all hospitals in the country.

"One of the problems we have observed is the issue of patients' families as caregivers in the wards," explains Arend, who was assigned to two hospitals in Dire Dawa and Jijiga. "Hospitals are understaffed and nurses cannot perform all of the duties that they typically perform in the developed world, namely, changing bedpans and linens, and feeding and bathing patients."

So patients' family members perform these duties. However, Arend explains, "Families in the ward lead to crowding, increased infection risk and disagreements with staff, at the same time they are performing essential services."

To address these issues, Arend worked with the head nurse and midwife in the maternity ward to develop a patient caregiver contract. "The contract formalizes the relationship between the caregiver and health-care workers," Arend explains, "limiting the number of visitors and listing the specific duties of the family caregivers under supervision of health-care workers." The contract is being piloted this year.

Grassroots Efforts

Progress is being made on a number of fronts: through international nongovernmental organizations (NGOs) such as WHO, the Population Council and Family Care International, local NGOs and individual efforts. Often the most significant progress is made by small groups and individuals working at the grassroots level.

With respect to the sexual and reproductive health needs of married and unmarried young people in India, for example, Jejeebhoy says, "I think there is finally recognition from government that these needs must be addressed. But the fact remains that marriage is still happening at a very early age, and young people are experiencing high HIV rates."

NGOs play a vital role in providing sexual and reproductive health programs for Indian youth, both married and unmarried, at the local level, Jejeebhoy says . For example, to address the needs of one vulnerable group of young people, young women who were newly married, pregnant or post-partum for the first time, the Population Council in partnership with two other NGOs launched the First-Time Parents Project, which provided sexual and reproductive health education and counseling, organized young women's social support groups, and sponsored community health activities in two villages in northern India. The project reached approximately 2,300 women through home outreach visits, 1,000 women who sought health services, and 1,000 women who participated in group activities. In an area of India in which young women typically live far from their families of origin, Jejeebhoy says, " The social support groups have continued even though the formal project has been completed."

Based on the results of the Population Council's research in Ethiopia, Erulkar's team worked with the Ethiopian Ministry of Youth, Sports and Culture to develop a program to address the needs of the most vulnerable girls. The program seeks to delay early marriage, reduce girls' social isolation, and support girls who are seeking to escape early marriage or exploitative situations. The community called the program "Berhane Hewan," which means "Light for Eve" in Amharic. With adult women acting as mentors, groups of married and unmarried girls between the ages of 10 and 19 meet for informal education and other activities of their choosing. "The meetings …have the effect of collectivizing girls, giving them safe and reliable spaces to meet, and building new and visible roles that are supported by the community," Erulkar writes in a paper about the project.

Moreover, the Ethiopian Ministry of Health has released a new Adolescent and Youth Reproductive Health Policy. "Our research had great influence on the policy: we sat on the task force to review the draft policy and made comments on drafts," Erulkar says. "The new policy draws heavily on key issues we've highlighted in our research, including a strong gender perspective, focus on married adolescent girls, and attention to the most vulnerable young people, such as migrants and domestic workers."

In Mali, Family Care International launched an HIV-prevention program to reach youth in "the informal sector," that is, outside the formal education system. This group includes apprentice electricians, cabinetmakers, truck-drivers and household workers, who are among those at highest risk for HIV infection but have the least access to information and services. Family Care International is partnering with a worker's association to train youth leaders to conduct sexual and reproductive health and HIV prevention outreach education with their peers, distribute condoms and strengthen referrals with health services.

By the end of this year, the program will have trained 100 youth leaders, who will reach an estimated 10,000 to 20,000 young people within Bamako, the capital. "We have a dynamic team of youth leaders who are engaged every day," Eyakuze-Di Domenico says, "and young people are interested in what they have to say because they are seeing that it is not the typical 'don't do this or that' approach, but one in which we provide education and ask them to take responsibility for their reproductive health decisions."

One of the youth leaders is a 27-year-old HIV-positive woman who was married at 16 and infected by her husband, who later died. "For youth to see a 'respectable' young woman from their own community who is HIV positive has a very strong impact," Eyakuze-Di Domenico says.

Reasons for Optimism

From their position on the front lines of efforts to improve sexual and reproductive health in some of the most challenging regions of the world, these Bryn Mawr alumnae feel progress is being made.

"I am optimistic about our ability to build the capacity of young people to educate their peers and put pressure on the government to implement reproductive health policies," Eyakuze-Di Domenico says. "We try to give these young people a sense that ‘I can do this.'"

As researchers, Erulkar and Jejeebhoy are building a knowledge base that can bring about change in policies and programs. "My motivation is to provide evidence that will enable programs to be modified enough to change people's lives," Jejeebhoy says. "As I travel, I see that in spite of all the poverty, we will make it."

"Change is slow, but it is happening," Arend observes. "I saw how far Ireland had come in the decade prior to my arrival in 2002, when the Irish Family Planning Association celebrated its 10th anniversary. The country had made major strides, although there still is a long way to go. The fact that we have made progress around the world, and the fact that these issues are on the table, are positive signs."

Fueling Arend's optimism, "I work directly with women who are making these changes happen at the grassroots level, and I am in awe of their resilience and determination."

As WHO Director-General Chan observed back in November, "… women are agents of change — for families, the workforce and entire communities."

About Our Sources

Elizabeth Arend '02 is a postgraduate fellow in the Yale University-William J. Clinton Foundation's Ethiopian Hospital Management Initiative, based in Dire Dawa. As a Thomas J. Watson Fellow in 2002-03, she studied reproductive health care, law and policy. Arend earned her M.P.H. in international and socio-behavioral health from the Johns Hopkins School of Public Health. On a Johns Hopkins Capstone Development Grant, she traveled to the West Bank to research her master's thesis, Healing Across the Divides: Forging Peace Through Public Health in the Occupied Palestinian Territories.

Annabel Erulkar '87 is director of the Population Council's Poverty, Gender and Youth Program in sub-Saharan Africa, based in Accra, Ghana, where she oversees a program of work related to vulnerable adolescent girls. She has conducted research on adolescent education, livelihoods, gender-based violence, sexual behavior and reproductive health. Prior to joining the Council, Erulkar was responsible for research and management information systems at the Family Planning Association of Kenya. She earned an M.S. in population sciences from Harvard University and a Ph.D. in social statistics from the University of Southampton, U.K.

Cynthia Eyakuze-Di Domenico '94 is acting director of the Francophone Africa Program at Family Care International, based in New York City, working on programs to help women and adolescents improve their sexual and reproductive health. Prior to joining Family Care International, she was a program associate with the Women's Environment and Development Organization, where she advocated for women's rights at the United Nations, including the 1995 Women's Conference in Beijing, China. Eyakuze-Di Domenico earned a B.A. and M.A. in French from Bryn Mawr College and an M.P.H. in epidemiology from Columbia University. She was named a Hepburn Fellow at Bryn Mawr College for 2007-08.

Shireen J. Jejeebhoy '73 is a senior program associate with the Population Council, based in New Delhi, where she directs research activities related to sexual and reproductive health and rights in India. Before joining the Population Council, Jejeebhoy worked at the World Health Organization in Geneva, Switzerland, as a scientist in the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction. Jejeebhoy earned a Ph.D. in demography from the University of Pennsylvania.


Dorothy Wright contributes news and feature articles on science, technology, engineering and general-interest topics to a variety of publications, including Civil Engineering and Engineering News Record.